Postpartum Hemorrhage (PPH)

• Postpartum hemorrhage (PPH) remains a major contributor to maternal mortality and morbidity worldwide.
• About half a million women die annually from causes related to pregnancy and childbirth.
• PPH affects the general condition of the mother, evidenced by increased pulse rate and falling blood pressure.
• PPH is defined as blood loss ≥500ml within 24 hours after birth; severe PPH is blood loss ≥1000ml within 24 hours.

Types of Postpartum Hemorrhage

• Primary PPH: Hemorrhage during the third stage of labor and within 24 hours of delivery.
• Secondary PPH: Hemorrhage occurring after 24 hours and within 6 weeks of delivery; also referred to as puerperal hemorrhage.

Causes of Postpartum Hemorrhage

Primary PPH

• Atonic uterus
• Trauma mixed (combination of both atonic and trauma).
• Retained product of conception.
• Uterine rupture.
• Uterine inversion.
• Blood coagulopathy.

Secondary PPH

• Retained bits of cotyledon or membranes.
• Infection.
• Cervico-vaginal laceration.
• Endometritis.
• Subinvolution of the placental site.
• Secondary hemorrhage from caesarean section.
• Other rare causes: chorion epithelioma, carcinoma cervix, placental polyp, fibroid polyp, and puerperal inversion.

Risk Factors

• Prolonged third stage of labor.
• Multiple delivery.
• Episiotomy.
• Fetal macrosomia.
• History of postpartum hemorrhage.
• Grand multiparity.
• Placenta previa.
• Placental abruption.
• Pregnancy-induced hypertension.

Symptoms

• Massive blood loss.
• Passing large clots.
• Dizziness, lightheadedness, or fatigue.
• Decreased blood pressure.
• Increased heart rate.
• Swelling and pain in the vaginal and perineal area.

Etiology

• Tone - Uterine atony.
• Tissue - Retained placenta.
• Trauma - Lacerations, uterine rupture.
• Clotting (Thrombin) - Coagulopathy.

Prevention of PPH

• Amniotic fluid embolism
• Retained dead fetus
• Inherited coagulopathy

Antenatal

• Improvement of the health status.
• High-risk patients.
• Blood group.

Intrapartal

• Slow delivery of the baby.
• Expert obstetric anaesthetist needed.
• Spontaneous separation and delivery of the placenta during caesarean section; includes active management of the third stage of labor.
• Examination of placenta.
• Induced or accelerated labor by oxytocin.
• Exploration of utero-vaginal canal.
• Observe the patient for about two hours after delivery.

FIGO recommendations: Prevention and treatment of PPH

• Involves active management of the third stage of labor.
• Includes administration of uterotonic agents (oxytocin 10 IU IM or misoprostol 600 µg orally if oxytocin is neither available nor feasible).
• Controlled cord traction.
• Uterine massage after delivery of the placenta, as appropriate.

Management

• Uterine massage
• Medication (oxytocin, carboprost)
• Gauze packing

Surgical

• Uterine Curettage
• Uterine Artery Ligation
• Hysterectomy

Retained

• Retained products of conception, often retained placenta or placental fragments, must be removed to stop the bleeding.
• Management: Oxytocin

Surgical

• D&C
• Administration of prophylactic antibiotics

Trauma

• Trauma resulting from the birth process can result in significant blood loss; the source of trauma must be quickly identified and treated.
• Vaginal bleeding is visible outside, either as a slow trickle or rarely a copious flow.
• Rarely, the bleeding is concealed either remaining inside the utero vesical canal or in the surrounding tissue space resulting in hematoma.

Management

• Emergency laparotomy
• Resuscitation
• Broad spectrum antibiotics.
• Observation for about two hours after delivery to make sure that the uterus is hard and well contracted before sending women to the ward.
• Adequate post-operative care.

Clotting

• Any derangement of hemostasis resulting in either excessive bleeding or clotting, although most typically it is defined as impaired clot formation.
• Examples: Abruptio placenta

Prevention of PPH

• Rub up the uterus to stimulate contraction and retraction.
• Administer ergometrine (0.2mg) intramuscularly.
• Syntometrine (1ml) intramuscularly may be given instead of ergometrine.
• Expel the placenta with the next uterine contraction by fundal pressure or controlled cord traction.
• Empty the urinary bladder by catheterization.
• A second dose of syntometrine or ergometrine may be given in ten minutes if bleeding is not controlled.

Treatment of True PPH

• If the uterus is soft, massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall.
• The posterior aspect of the uterus is massaged with the abdominal hand and the anterior aspect with the vaginal hand.

Uterotonic Agents

• Uterotonic agents include oxytocin, ergot alkaloids, and prostaglandins.
• Oxytocin - 10 international units (IU) should be injected intramuscularly, or 20 IU in 1 L of saline may be infused at a rate of 250 mL per hour. As much as 500 mL can be infused over 10 minutes without complications.
• Methylergonovine (Methergine) and ergometrine, a typical dose of methylergo-novine, 0.2 mg administered intramuscularly, may be repeated as required at intervals of two to four hours.

Prostaglandins

• Carboprost can be administered intramyometrially or intramuscularly in a dose of 0.25 mg; this dose can be repeated every 15 minutes for a total dose of 2 mg.
• Misoprostol is another prostaglandin; It can be administered sublingually, orally, vaginally, and rectally. Doses range from 200 to 1,000 mcg; the dose recommended by FIGO is 1,000 mcg administered rectally.

Lacerations and Hematomas

• Lacerations and hematomas, resulting from birth trauma, can cause significant blood loss that can be lessened by hemostasis and timely repair.

Uterine Rupture

• Symptomatic uterine rupture requires surgical repair of the defect or hysterectomy. Uterine inversion is rare.

Hysterectomy

• A surgical operation to remove all or part of the uterus in case of life-threatening condition of the women i.e., menorrhagia, post-menopausal period.

Dystocia

• Defined as long, difficult, or abnormal labor, is a term used to identify poor labor progression.
• Dystocia may arise from deviations in the powers, the passenger (fetus), or the passageway (maternal pelvis),.
• Dystocia may be related to maternal positioning during labor, as well as fetal malpresentation, anomalies, macrosomia and multiple gestation.
• Maternal psychological responses to the labor, based on past experiences, cultural influences, and the woman's present level of support may play a role in the normal progress of labor.

Factors Associated with an Increased Risk for Uterine Dystocia

• Uterine abnormalities, such as congenital malformations and overdistention (e.g., hydramnios, multiple gestation).
• Fetal malpresentation or malposition o Cephalopelvic disproportion (CPD).
• Maternal body build (30 lbs. [13.6 kg] overweight, short stature).
• Uterine overstimulation with oxytocin.
• Inappropriate timing of administration of analgesic/anesthetic agents.
• Maternal fear, fatigue, dehydration, electrolyte imbalance.

Pelvic Dystocia

• Pelvic dystocia occurs when contractures of the pelvic diameters reduce the capacity of the bony pelvis, the midpelvis, the outlet, or any combination of these planes.
• Contractures of the maternal pelvis may result from malnutrition, neoplasms, congenital abnormalities, traumatic spinal injury, or spinal disorders.
• In addition, immaturity of the pelvis may predispose some adolescent mothers to pelvic dystocia.
• During labor, contractures of the inlet, midplane, or outlet can cause interference in engagement and fetal descent, necessitating cesarean birth.

Soft Tissue Dystocia

• Soft-tissue dystocia occurs when the birth passage is obstructed by an anatomical abnormality other than that involving the bony pelvis.
• The obstruction, which prevents the fetus from entering the bony pelvis, may be caused by placenta previa, uterine fibroid tumors (leiomyomas), ovarian tumors, or a full bladder or rectum.
• Bandl ring is a pathological retraction ring that develops between the upper and lower uterine segments.
• It is associated with protracted labor, prolonged rupture of the membranes, and an increased risk of uterine rupture.

Post-Patum Hematoma

• These are localized collections of blood in loose connective tissue beneath the skin covering external genitalia, beneath the vaginal mucosa or in the broad ligaments. Sometimes it occurs without laceration of the overlying tissue.

Pathophysiology and Etiology

• Trauma during spontaneous labor Trauma during operative vaginal delivery
• Inadequate suturing of an episiotomy
• Delayed homeostasis of difficult or prolonged second stage of labor or both

Clinical Manifestations:

• Complaints of pressure and pain o
• Pain may be verbalized excruciating.
• Discolored skin that is tight, full feeling, and painful to touch
• Possible decrease in BP, tachycardia
• Decreased or absence of lochia flow

Management:

• Small hematomas (<3cm) are left to resolve their own: Ice packs
• Large hematomas (>3cm) may require evacuation of the blood and ligation of the bleeding vessel

NCM 109-BSN

Analgesics and broad-spectrum antibiotics

• Analgesics and broad-spectrum antibiotics may be ordered due to increased chance of infection

Complications

• Hypovolemic shock, shock from extreme blood loss
• Anemia, infection
• Increased length of postpartum period
• Calcification and scare tissue
• Dyspareunia (painful intercourse)

Nursing Intervention

• Insect the perineal and vulvar area for signs of hematoma periodically postpartum
• Inspect the vaginal area for sign of hematoma if woman is unable to void
• Monitor vital signs periodically and evaluate for signs of shock
• Relieve pain of hematoma:
• Apply ice bag to perineal area
• Medicate with mild analgesics
• Position for comfort to decrease pressure on the affected area
• Catheterize patient of unable to void
• Teach the woman the importance of eating a balance diet and to include food rich protein and vitamin C.

Post-Patum Infections

Types of Puerperal Infection:

• Endometritis
• Wound Dehiscence
• UTI
• Mastitis
• Septic pelvic thrombophlebitis

Endometritis

• During the immediate postpartum period, the most common site of infection is the uterine endometrium.
• This infection presents with a temperature elevation over 101°F (38.4°C), often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.
• Since urinary tract infections can occur during any part of the pregnancy and puerperium, differentiating the various signs and symptoms is important.
• As noted, other infections are more likely to occur following discharge from the hospital.
• Therefore, follow-up in the home or clinic by a nurse or primary care provider may offer the first opportunity to identify infectious processes.

Mastitis

• Mastitis is usually unilateral and develops after the flow of milk has been established.
• The most common causative organism is Staphylococcus aureus, introduced from the infant's mouth through a fissure in the nipple.
• The infection involves the ductal system, causing inflammatory edema, enlarged axillary lymph nodes, and breast engorgement with obstruction of milk.
• Without treatment, mastitis may progress to a breast abscess.
• Symptoms include fever, malaise and localized breast tenderness.
• Management centers on antibiotic therapy (e.g., cephalosporins and vancomycin), application of heat or cold to the breasts, hydration, and analgesics.
• To maintain lactation, the woman may empty the breasts every 2 to 4 hours by breast feeding, manual expression, or breast pump.
• Since mastitis usually occurs after hospital discharge, an important component of nursing care includes teaching the breastfeeding mother about signs of mastitis and strategies to prevent cracked nipples.

Wound

• The surgical incision requires ongoing nursing assessment after a cesarean birth.
• The nurse should assess for approximation of the wound edges, and make note of any redness, discoloration, warmth, edema, unusual tenderness, or drainage.
• If a dry sterile dressing has been applied, the surrounding tissue should be carefully evaluated for evidence of a reaction to the tape used to secure the dressing.
• Assessing for and effectively treating incisional pain is also of paramount importance.

Urinary Tract Infections

Risk Factors

• Catheterization, multiple vagina exam, poor postpartum hygiene, genital tract trauma, epidural anesthesia, PROM, history of UTIs during pregnancy

Septic Pelvic Thrombophlebitis

• Septic pelvic vein thrombophlebitis is an extremely rare condition.
• It occurs after delivery when an infected blood clot, or thrombus, causes inflammation in the pelvic vein, or phlebitis.
• Only one in every 3,000 women will develop septic pelvic vein thrombophlebitis after delivery of their baby.
• Symptoms usually occur within a week after giving birth.
• The most common symptoms are the following: Fever, chills, abdominal pain or tenderness, flank or back pain, a "ropelike" mass in the abdomen, nausea and vomiting.
• The fever will persist even when taking antibiotics. Special Considerations of Pregnant Women With HIV
• Women who have the human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) require special precautionary care during the puerperium.
• All personnel who come in close contact with the patient should wear latex gloves (unless the patient has a latex allergy).
• In that situation, nonlatex gloves are used, as well as safety glasses to prevent the transmission of blood and body fluids.
• Patients need to be taught to avoid contact of personal body fluids with the infant's mucous membranes and open skin lesions. Breastfeeding is not advised due to the risk of transmission of HIV to the infant.

Emotional and Physiological Adjustments During the Puerperium

• Many mothers experience a roller coaster of emotions after childbirth.
• These feelings stem from a number of influences and are often linked to perceptions concerning the fulfillment of expectations surrounding the childbirth experience.
• A complicated birth, a premature birth or a sick infant, as well as the woman's parity, age, marital status and stability of family finances are some of the many factors known to shape emotions experienced during the postpartum period.
• The first 3 months after birth are recognized as the most vulnerable emotional period for mothers.
• Insecurity about infant care, the constant demands associated with caring for the baby, sleep deprivation, and minimal social support create the potential for frequent and dramatic mood changes.
• Rapid hormonal changes during the first few postpartal days and weeks may give rise to mood disorders.
• The most common of these is often termed "the blues."
• Other less common puerperal mood disorders include postpartum depression and postpartum psychosis.

Maternity/Baby Blues/Postpartum Blues

• The "maternity blues" are considered to be a normal reaction to the dramatic changes that occur after childbirth including abrupt withdrawal of the hormones estrogen, progesterone and cortisol.

Baby Blues Interventions

• The "blues" are treated with support and reassurance.

Nurses Role On PPD

• In this setting, the nurse needs to be alert for subtle cues from the new mother, such as making negative comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance.
• Does she look unkempt or exhausted? Is the baby clean and dry?
• Does the new mother say something about needing- more help at home?
• Did she come to the office or clinic with the baby (and other children) or by herself?

What is deep vein thrombosis?

• Deep vein thrombosis or DVT occurs when blood clot(s) form in the deep-seated veins. It is common to occur in the legs during pregnancy due to increased pressure or strain on the lower body.
• These blood clots can have serious consequences when not attended in time. Why does it occur in pregnancy?
• Hormonal changes - can make the veins and valves smooth that can lead to impaired functioning
• Increased blood volume while the number of veins remains the same
• Significant increase in weight

How to Diagnose?

Diagnosis:

• D-dimer blood test D dimer is a type of protein produced by blood clots. Almost all people with severe DVT have increased blood levels of D dimer. A normal result on a D-dimer test often can help rule out PE